Thursday, February 19, 2009

Compliance Therapy with Psychotic Patients

I found an article from the UK that discuses the uses of compliance therapy with psychotic patients. It's an interesting article with some relevance to social work practice. However, what I want you to do is try your hands at a little criticial analysis. Read the article but specifically focus on the methods section. Look for terms that you recognize from our class discussions. I want you to comment on the article with a specific focus on the methodology used by the researchers. I'm interested to see your comments.

What I found interesting about the study is that the researchers found that the gains of the study actually translated into substantially improved functioning of the subjects. Further, researchers admitted they do not yet know if the gains will have a positive cost-benefit analysis in terms of the intervention administered. Lastly, researchers admitted they were not sure if the improvements in functioning were a direct or indirect result of their intervention. At least they were honest about their results; however, one would want to search for other models of interventions that resulted in better outcomes.

They had a control group compared to the intervention group. They defined clearly the two different groups. Both groups were assessed prior to the intervention and then after to determine the results. They went into great detail as to who the active participates were and acknowledged there could be observer bias. Although they felt the intervention resulted in higher compliance they did state they were not sure it was cost-effective.

Response to Denise:I too thought it was interesting that the researchers admitted they were not sure if the imporvements in functioning were a direct or indirect result of their intervention. At least they were honest.

How was the exclusion criteria determined?Why was the assessment time within one week? Why not at the time of intake or a day or two after?How did patients that had spent some time in the intensive care unit still fit the criteria?Were just women included in the study?Why were there so many tools/tests for the assessments?Who conducted the tests/assessments?

If I were researching this idea, I would not use compliance therapy based on the findings in this article. In the discussion, it states that they could not be sure that the gains would translate into substantially improved functioning or prevention of relapse. They futher stated that they could not be sure that the improvement was a diret result from the intervention. They also admitted that there may have been some biases from the researchers. Before I would use compliance therapy as an intervention for my clients, I would need more research to be done in this area. There are too many question that are vague and left unanswered for this to be a reliable and valid research study. I don't think that this research is generalizable and representative of psychotic patients and their ability to comply with their medications.

I think that we recognized most of the same words/terms in this study. I agree with you Denise when you say that other methods of interventions need to be assessed when making a decision about this intervention. I really don't think that they proved anything to me in this article. I think that I get what they were trying to prove, but they don't have enough evidence to back up their claims. I agree with you both when you say that at least they were honest. I think that is a good thing that they did address the areas of limitations for this study and admitted that more research needed to be done in this area.

As I read the methods section of this study, I noticed that the ethnicities of the participants were not specifically stated. The participants were labeled either white or non-white. As we discussed in class, it is important to know the cultures that you are working with while conducting research. If participants feel like their culture is not being acknowledged, they may not give valid and reliable answers, which in turn may skew the results of the study. It is also important to acknowledge all ethnicities that are being studied in order to have a better understanding of the results and how the results relate to each participant. Not only will the study be more precise, representing all ethnicities in a study will help other researchers in determining the specific views of all ethnicities. Also, the study may be perceived as biased since there was not equal representation of all ethnic groups.

Response to Diane WatsonBy Carrie Wells

It was mentioned in the study that there could be observer bias, which I agree with considering the researchers did not identify the various ethnicities of the participants. By only recognizing one ethnicity, as they did with the description “white” or “non-white,” it demonstrates that the researchers, and possibly the observers, viewed the participants with an ethnocentric lens and did not take into account the differences in cultures.

It was mentioned in the study that there could be observer bias, which I agree with considering the researchers did not identify the various ethnicities of the participants. By only recognizing one ethnicity, as they did with the description “white” or “non-white,” it demonstrates that the researchers, and possibly the observers, viewed the participants with an ethnocentric lens and did not take into account the differences in cultures.

In reading the objective of the study, my first inclination was that I had no clue what it was communicating. As I re-read the objective, I realized that if I took my time that I could understand it. It reminded me how Josh always says that it’s a different language and it takes time to get used to the language that researchers use.

In his lecture on Saturday, Josh talked about how quantitative research uses non-probability sampling. This study seemed to use non-probability sampling in that the population required a certain criteria. The study excluded “non-English speakers and subjects with a low intelligence quotient, deafness or organic brain diseases.” Prior to learning about quantitative research, I would not have been able to distinguish the difference in exclusion with a purpose and discrimination.

At the end of the article, the limits of the research are acknowledged. This acknowledgment helps the reader to understand the reliability of the results. It also helps other researchers to consider these factors if they decided to do a similar study. In which case maybe they can set more control to certain aspects. However when dealing with quantitative research, one of the downfalls to non-probability sampling is that there is less control.

I agree that further research should be done before using compliance theory as a "evidence-based practice." While the study seems to have advanced from previous studies that were "not randomised," further controls need to be put into place into order to determine causation in relation to compliance.

In reading the objective of the study, my first inclination was that I had no clue what it was communicating. As I re-read the objective, I realized that if I took my time that I could understand it. It reminded me how Josh always says that it’s a different language and it takes time to get used to the language that researchers use.

In his lecture on Saturday, Josh talked about how qualitative research uses non-probability sampling. This study seemed to use non-probability sampling in that the population required a certain criteria. The study excluded “non-English speakers and subjects with a low intelligence quotient, deafness or organic brain diseases.” Prior to learning about qualitative research, I would not have been able to distinguish the difference in exclusion with a purpose and discrimination.

At the end of the article, the limits of the research are acknowledged. This acknowledgment helps the reader to understand the reliability of the results. It also helps other researchers to consider these factors if they decided to do a similar study. In which case maybe they can set more control to certain aspects. However when dealing with qualitative research, one of the downfalls to non-probability sampling is that there is less control.

In regard to research terms mentioned in the article, I recognized the following: randomised controlled trial,subjects,measure,treatment,control group,intervention,method,systematically evaluated,study,interviewing,pilot study,population,mean,assment,model,measure,regregression, and validity. In terms of the effectiveness of the study,I thought the data collected from the researchers was extremely informative because they not only considered the benefits of the study, but the limitations as well. Based on the researchers conclusions that the benefits did not necessarily outweight the costs, other methods and measures should be explored in an effort to develop a more comprehensive and benefical result. In terms of the study's outcome, I did not find that the results were very concise or clear due to the lack of evidence presented in the study. Therefore, by all indications, alternate research methods should be assessed and evaluated. -Melanie Reeves

In conclusion to the previously posted comments regarding the element of honesty incorporated throughout the study, I too found it refreshing that the researchers listed the benefits, as well as, the limitations of the study.As a result, future subjects can make a more informed decision as to whether to pursue compliance therapy or not.-Melanie Reeves

When I read this article the one comment that stood out to me in the article was related to the control group. The article states "the same therapists listened to the patients' concerns but declined to discuss treatment" as they had with the patients involved in the intervention group. The patients in the intervention group were given extensive information regarding how the drugs could benefit them and also information regarding the side effects. They were able to review their history of illness and get a complete picture of possible treatment interventions. The patients in the control group were given only supportive counseling. It would seem to me that in this type of treatment that medication therapy would be common anyway and should be discussed with all patients if possible. It seems as though the control group had information withheld. I wonder if this was the normal practice already or did they just intentionally not tell the patients in the control group about information they had normally explained to them in the past. Additional questions I had were related to the participants' competence. Were they able to consent to participate in this study? These are the issues related to the methods used that I questioned as I read this article.

The article title includes the phrase, “randomized controlled trial”. I do not see how the study was random. The patients were from the same hospital. The sample does not appear to be a true representation of the psychotic patient population. Again, all of the patients chosen for the study were from the same hospital, not various hospitals. Another issue I had with this study was that I did not understand how it was determined that the compliance therapy had an impact on the attitude of the patients toward drug treatment. The study stated that 25 patients showed this improvement, but 16 of these patients were on additional medications consisting of anti depressants or lithium. How were they able to be certain that this improvement was due to compliance therapy and not the medications that enhanced compliance?

In response to Melanie's post, I felt that other research conclusions should have been included. I guess that this was not the point, though. They were just evaluating this one variable. I guess a study does not have to be necessarily successful but just reliable.

Orginal Post Deidre,Overall, I found the article to be intresting but there was inconsistent in the study to obtain a valid number of compliance with treatment. In the intervention group versus the control group lack of consideration was given. Coming from a background of a mental health case manager I notice that the reseach does not give enough consistent with compliance from patients. How are they actually conducting this research and do they have approval too form the study. There were several terms that I notice in the article.Random, random assignment, variables, outcome measures, analyis,interventions, results,control group, efficacy, and generalisable.

Respone to Julie by:DeidreI total agree with you, I could not see how the study was formed the same hospital. You would think that the study would have been selected from several hospitals instead of the same one. Yeah! I read want they stated about 25 patients showed improvement and there were others on anti depressants and lithium. With that type of medication I really think that it could have been compliant for those who were on those med because they were in a safe haven environment, I can see some control compliance.

Some of the terms I recognized from the article include randomly assigned, control treatment, study population, subjects, controlled study and intervention. I was concerned that I did not see how informed consent was obtained from the patients since they were psychotic patients. The article did not mention the method used or if consent was given by guardians or relatives of the patients. The 47 remaining patients suffered from severe affective disorders and their conditions were chronic. Malinda S.

Response to Kristi MaddoxKristi I noticed that the therapist would listen to their concerns of both groups and declined to discuss the treatment in the control group. Yet in the discussion section, there is no mention of providing an explaination to the patients that information regarding the treatment was withheld. Malinda S.

In response to Melinda LanierMelinda when I first read and re-read the article, I was still surprised to see how little I understood about the article, with the exception of looking for information on how informed consent was obtained for these patients because of the nature of their illness. Malinda S.

I too questioned why there was more than one tool for conducting the assessment. Would it have not more beneficial to have one tool in which to provide the measurement? I also think that it would have been better to have the same person conduct the assessment at each interval to ensure consistency. I just think that this made the study too complicated.

The study utilized those individuals 18-65 who had been admitted to the hospital with acute psychosis over an eight month period. They excluded Non –English speaking subjects and those subjects with low IQ, deafness, and brain disease so it was not generalizable to these persons. Of those left, 12 subjects refused and nine were discharged rapidly. The remaining subjects were pre-screened. The subjects were randomly assigned to either the intervention or the control group. Then the subjects were reassessed following the intervention. One thing I noticed was both interventions were conducted using the same therapist. I could see they made not want to say that a change occurred because one therapist was more engaging but what about the ramifications? All participants were afforded routine care after the study was completed. Initial compliance was rated bind to intervention by the patients’ primary nurses. Were all the ratings repeated before discharge and after the intervention rated blind as well? The composite compliance measure utilized as many sources as possible (friends, relatives, psychiatrist, nurses, etc.) and I thought that was good. Also, the sixth evaluation was carried out a community nurse who was blind to intervention. The researchers explained to some degree whether the study was generalizable and noted the population that might benefit from the information contained in the study. They also discussed some of the limitations of their study. Some of the words I recognized in the article were randomized controlled trial, intervention group, study population, randomly assigned, observer bias, variables, subjects, and generalisable.

I agree with your post. I enjoyed the fact that researchers were able to state their limitations and were able to inform the audience that this may not be cost effective. I agree those looking for the best course of treatment for psychosis should look at a variety of evidence based methods and decide what methods best fit with the client and what the agency can offer.

A few of the words I recognized in this article from class include: random, control, population, randomly assigned, measures, results, assessment, and compliance. I’m curious as to how the researchers received approval for this study. I thought participants/subjects needed to receive informed consent; they studied psychotic patients. I also noticed the article stated, “The control treatment consisted of a similar number of sessions (mean 4.9) of supportive counseling in which the same therapists listened to the patients' concerns but declined to discuss treatment.” I understand this was not conducted in the U.S., but I don’t think this is ethical, unless I misunderstood the article. I would look for more information, along with this article, if I was researching “compliance therapy”

A few of the words I recognized in this article from class include: random, control, population, randomly assigned, measures, results, assessment, and compliance. I’m curious as to how the researchers received approval for this study. I thought participants/subjects needed to receive informed consent; they studied psychotic patients. I also noticed the article stated, “The control treatment consisted of a similar number of sessions (mean 4.9) of supportive counseling in which the same therapists listened to the patients' concerns but declined to discuss treatment.” I understand this was not conducted in the U.S., but I don’t think this is ethical, unless I misunderstood the article. I would look for more information, along with this article, if I were researching “compliance therapy”

I agree; I would not solely use this article in reference to compliance therapy as well. The introduction stated that other comprehensive, behavioral studies had been conducted, but did not give the data on compliance. Thus they further investigated. The results of the research are not as beneficial when the researchers are unsure of the effectiveness.

Some of the terms I recognized from the lecture: validity, measure, subjects, method and results. In the methodological considerations there were several biases in the study mentioned. I am wondering if the study was in compliance with the IRB. I am also wondering if these psychotic patients knew what type of study that was being conducted on them and if there were as stable as they could be. I also did not see any type of consent from the psychotic patients. Even though the study of compliance therapy had an outcome, my question is how accurate is it.

We know because of the study that the patients were psychotic and not in the U.S. and I also question how were they able to gain consent if they did, are their laws for conducting studies/ research the same or different from the U.S. and is the research questionable with the findings.

Since the researchers did admit that their findings may not be as accurate as possible, I would also do more research to better understand the study and the findings on Compliance Therapy with Psychotic Patients. At least there were honest.

In focusing on the methodolgy portion of the study, there were several questions that came to mind when I read it. How was consent obtained and by who? How well does this hospital represent the psychotic population in London? Also, in the introduction section they stated "Among the most powerful predictors of compliance are attitudes to treatment and insight into illness. Other possible determinants include culture and ethnic group...". My question is were they able to obtain a population to really measure if culture and ethnic group played a role in compliance? Again, they were studying individuals from one hospital, which depending on where it was located, may have only attracted certain particular ethnic groups. I think the methods section could have been more detailed to include information about obtaining consent and the location of the hospital. Seeing as I have never been to London, "an inner London catchment area", means nothing to me.

I agree with you that the study was not random in that they made a selection of participants from one hospital. It is hard to get a true sample of the population when studying individuals living in the same area.